Addiction Flashcards
awful feeling, no sleep last night, visible sweating and a tremor.
PMH: panic disorder treated with benzodiazepines.
Non smoker, drinks alcohol. Takes xanax.
Dx?
benzodiazepine withdrawal
Ix for ?benzodiazepine withdrawal
UDS
Mx of ?benzodiazepine withdrawal
give a long acting benzo and taper it down
can benzo withdrawal be lethal?
YES
when can benzos be used
no other choice for severe anxiety
rapid tranq
medical reasons eg epilepsy
risk factors for benzo withdrawal
prolonged use
high doses
short acting benzos
MoA of benzos
target gaba a positive allosteric modulators –> bind so receptor has greater affinity for gaba –> increased flow of Cl- –> hyperpolarisation –> reduced excitability & less likely to fire
withdrawal features of benxos
anxiety
irritability
restlessness
tremor
sweating
insomnia
confusion
seizure / psychosis risk
toxicity of benzos
drowsy
ataxia
slurred speech
reduced conciousness
toxiticy of benzos
hypotension
bradycardia
antidote to benzos
flumazenil (antagonist)
how is benzo dependance managed
GP / addiction services
convert to diazepam equivalent dose daily (up to 40mg OD)
very slowly reduce the dose - no more than 10% every 2 weeks
what can be tested on UDS
amphetamines
barbiturates
benzos
cocaine
ectasy
meth
morphine
methadone
opiates
TCAs
cannabis
range of detection of cannabis in UDS
casual use - 1-14 days
heavy use up to 30 days
range of detection of other drugs in UDS
2-6 days ish
back injury with codeine 60mg every 4 hours, 4 times per day. comes in saying she lost prescription so needs another & has contacted OOHs to get more separately. admits to buying co-codamol too, and taking more than prescribed.
says she has withdrawal Sx when trying to cut down. Dx?
opioid dependance
red flags of opioid dependence Hx
lost prescription
going to different pharmacies to get max amount
buying meds off friends
define harmful use
a pattern of psychoactive sybstance use that is damaging to health
- physical or mental damage
define substance abuse / dependence
the continued misuse of any psychoactive substance that severely affects a person’s physical and mental health, social situation and responsibilities
what is a psychoactive substance
substance that has an effect of central nervous system
define the 6 criteria of ICD 10 dependence syndrome
- strong desire / compulsion to take substance
- difficulties controlling substance taking behaviour
- physiological withdrawal state when they stop using substance
- evidence of tolerance
- progressive neglect of alternative pleasures or interests
- persisting with substance use despite clear evidence of overtly harmful consequences
how many criteria are needed for a diagnosis of dependence with ICD 10 criteria
3+
stages of change model
pre contemplation
contemplation
preparation
action
maintenance
relapse OR abstinence
what method can you use to move someone from pre contemplation to contemplation
FRAMES
- feedback about risk / impairment
- responsibility for change is placed on pt
- advice given to pt
- menu of alternative self help / treatment
- empathic style used
- self efficacy / optimistic empowerment
Ix for ?alcohol dependence
CAGE / AUDIT / FAST questionnaire
LFTs
Alcohol Hx questions
what / how much / when / where drinking
alone or with friends
withdrawal - what / when / alcohol needed to overcome
triggers for drinking
binging / steady drinking
longest period of abstinence
any help sought for drinking / psych conditions
drugs / crimes
FH
how do you calculate units of alcohol
[ABV x volume (mL)] / 1000
define alcohol dependence syndrome (Edwards and Gross 1976)
narrowing of drinking repertoire
salience of drink-seeking behaviour
increased tolerance
repeated withdrawal syndrome
relief / avoidance of withdrawal Sx by further drinking
subjective awareness of compulsion to drink
reinstatement after abstinence
do alcoholics have 1 drink of choice or will they drink any alcohol
1 drink of choice usually
Mx of alcohol dependence
- inc meds, therapy, laws
motivational interviewing & discuss evidence for concern
initiate discussion of Mx for reduction of drinking
offer referral to specialist alcohol services
must notify DVLA by law
offer prophylactic oral thiamine to harmful / dependent drinkers if malnourished
use a daily drink diary
follow up
list 4 alcohol abstinence medications and their use
acamprostate - reduced hyperglutamtergic state, increases abstinence. anti craving drug.
naltrexone - reduces relapse rates (licesned for opiates)
disulfram - inhibits liver enzymes that metabolise alcohol, so is an aversive if alcohol is drank. can be dangerous if alcohol is drank as increased acetyldehyde.
nalmafene - opioid antagonist. start when drinking to reduce consumption / stop binge drinking.
which drug is an anti alcohol craving drug
acamprostate
which drug increases hangover symptoms more quickly (aversive)
disulfram
which drug is contraindicated in alcohol dependence
nalmafene - only for binge drinking episodes, not constant drinking
Ix for alcohol withdrawal
basic obs
abdo exam - organomegaly
neuro exam - tremor / pupils
bloods - FBC, LFTs, thiamine, clotting
Mx of alcohol withdrawal
chlordiazepoxide - reducing regime over 7-10 days
thiamine / pabrinex
do NOT give glucose prior to pabrinex as it can precipitate wernickes
what is alcohol withdrawal
when alcohol dependent stops drinking, is potentially lethal
risks of alcohol withdrawal
wirhdrawal seizures, Delirium tremens, wernickes, korsakoffs
symptoms of alcohol withdrawal
tremors
sweating
N&V
anxiety
HTN, tachycardia, dilated pupils
psychomotor agitation
psychotic Sx - delusions / hallucinations
withdrawal seizures
what % people get withdrawal seizures in alcohol
20%
when do alcohol withdrawal seizures occur
24-48 hours after last drink
what type of seizures are alcohol withdrawal seizures
tonic clonic
when do symptoms occur in alcohol withdrawal
6-12 hours after drinking has stopped
when is pabrinex not used in alcohol withdrawal
significant hepatic impairment
when does delirium tremens occur
24-72 hours after alcohol has stopped
sx of DT
withdrawal + alterted mental status - hallucinations / confusion / delusions /severe agitation
+/- seizures
risk factors of DT
previous DT
previous alcohol withdrawal seizures
infection / medical problems
recent higher than normal alcohol
abnormal LFTs
older age
Mx of DT
admit to hospital
benzos
pabrinex
treat hypoglycaemia AFTER
magnesium to prevent arrhythmias
mortality of untreated DT
35%
mortality of early recognition and TX of DT
2-5%
why does wernickes / korsakoffs occur
thiamine deficiency –> oxidative damage / apoptosis of neurones / glial cells / astrocytes
why are alcoholics thamine deficient
poor diet
stomach lining damage so poor absorption
which one of korsakoffs and wernickes is reversible
wernickes
sx of wernickes
confusion –> main one
opthalmoplegia - nystagmus or CN6 palsy
ataxia
what % of people have 3/3 wernickes sx
25%
korsakoff’s psychosis sx
profound anterograde and retrograde amnesia
confabulation
frontal lobe dysfunction - child like personality
psychotic sx
what is clucking
term used by opioid users to describe withdrawal sx as you get goosebumps
low BP, low O2 sats, pin point pupils, unresponsive to pain. Dx?
opioid overdose
Tx for opioid overdose
ABC approach w IV fluids
IV naloxone every 1-2 mins depending on response. titrate dose up until response seen
risk factors of opiate overdose
opiate naive / reduced tolerance
older
hepatic / renal impairment
lung disease - COPD
prescribed / using other sedatives
clinical features of opiate OD
reduced GCS
respiratory depression
hypotension & tachycardia
hypotonic / hyporeflexic coma
pin point pupils
prophylaxis for opiate OD
give addicts / ppl with opiates prescribed an IM naloxone pen
2 types of opiate substitution therapy
methadone
buprenorphine
features of methadone
- half life / action
- action
- side effects
long acting, half life 24 hours, used once a day
reduced slowly over weeks, less euphoria than heroin
side effects: letahrgy, resp depression, contipation, reduced saliva
features of buprenorphine
- action
- half life
- comparison to methadone SE
partial agonist, long half life, adminsitered once a day
attentuates effects of opiates
produces less sedation, less euphoria, positive reinforcement, less resp depression
what is buprenorphine + naloxone called
suboxone
- no longer used
how is OST done in acute setting
confirm the substitute and dose with GP and then with the chemist
UDS - check for methadone
prescribe the dose if above are fine
call chemist when discharged to inform them
is opiate withdrawl lethal
Not really, but can be due to vomitting leading to dehydration
withdrawal Sx onset for heroin
6hrs after last
peaks 26-48 hours after
withdrawal sx onset for methadone
1-2 day half life
starts 36 hours and peaks 3-5 days later
when does heroin withdrawal complete
5 days
features of opiate withdrawal
sweating, yawning, lacrimation, flu like sx
tremor
tachycardia, HTN
GI upset
piloerection or goosebumps –> hence clucking
scale for opiate withdrawal rating
COWS - clinical opiate withdrawal scale
